Skype ≠ Telemedicine

I got a call from a vendor trying to develop a video conferencing product for a physician to use to talk to a patient who is at home. He said “I’m having trouble finding codes for telemedicine that the doctor can use.” Aren’t we all.

Talking to your patient using a secure video connection doesn’t meet the criteria for telehealth as developed by CMS. There are no current CPT codes that describe that situation. There is no way to report it to the insurance company and be reimbursed for the service. There are CPT codes for non-face-to-face services such as phone calls and on-line medical evaluations, but they don’t describe a video discussion with a patient and have a status indicator of non-covered. (Insurance won’t pay, bill the patient). Interprofessional telephone/internet consultation codes describe physician-to-physician consults and have a status indicator of bundled. (No one will pay.)

What about CMS’s telehealth benefit? Telehealth is a covered service between a patient in an originating setting that is in a Health Professional Shortage Area or in a county outside of a Metropolitan Statistical Area. The originating site is a physician office, hospital, critical access hospital, rural health clinic, federally qualified health center, skilled nursing facility or community mental health center. Home is not one of the locations. The patient is located in one of these settings and their provider requests that a distant health professional assess and treat the patient through video-conferencing. There are specific CPT codes that may be reported in these instances. Telehealth as currently defined does not mean that a physician or healthcare professional uses a video-conference to treat their own patient.

Now, you’ll tell me we are moving from fee-for-service medicine into caring for our patients in a way that doesn’t require them to drive to our offices. We have mobile apps for monitoring their well being, and our goal is to keep them healthy and not consuming healthcare resources. (That’s a euphemism for driving up costs we’re at risk for.) But, most of us aren’t there yet. Most of our revenue comes from fee-for-service and there is no CPT or HCPCS code that currently describes a physician using video-conferencing to talk with their patient.

You can download CMS’s telehealth fact sheet



Clues that your SCRIBE is in DISGUISE

Scribes in medical practices are in the news as a way for physicians to more effectively care for patients and use their EHRs. The scribe enters the exam room with the physician and does all of the data entry or typing while the physician takes the history, does and describes out loud the exam and develops the treatment plan with the patient. The scribe doesn’t interact directly with the patient at all, and probably isn’t the medical assistant who roomed the patient. The scribe writes, “Scribed by Betsy Nicoletti.” The physician reviews the scribed note, edits it and signs it.

 But, sometimes, medical practices don’t understand the concept of a scribe. Here are tell tale clues that the person who is “scribing” isn’t really a scribe.

  • Instead of saying, “Scribed by Betsy Nicoletti” the note says, “Dictated for Dr. Palmisano.” Huge warning sign!
  • Your scribe is disguised as a student: Medical student services are never billable services, and a medical practice can’t use the student documentation as a basis for submitting a claim to an insurance company. It usually isn’t the model for students. The student doesn’t sit and type while the clinician asks questions and examines the patient, as a scribe does. In case you need more information on this, page down to my most recent post. This relates to PA and NP students, as well.
  • Your scribe is disguised as an NP or PA or physician with an advanced degree: But, the practice has neglected to enroll the PA or NP with insurances because the medical professional is “only filling in for this week” or “really never works on his/her own.” This is an enrollment issue. Medicare and Medicaid enroll physicians, NPs and PAs, so get them enrolled and report the services appropriately. Contracts with commercial insurers vary. In some models, the PA/NP sees the patient first, does the bulk of the documentation and then the physician arrives and does a briefer visit. Report that service under the PA/NP provider number. “Dictating for Dr. Orthopedist” is not scribing as defined above and does not allow you to report the service under Dr. Orthopedist’s NPI.
  • Your scribe is disguised as an NP or PA and is doing a procedure that typically only a physician or NP or PA would do. Re-read the above example. Your PA/NP may perform procedures independently or incident to. If independently, report under the NP/PA provider number. If incident to, be sure the Medicare incident to rules are met.
  • Your scribe is disguised as you, in the room without you, asking questions or doing an exam, disguised as an independent practitioner: Scribes are typically medical assistants trained to work with a clinician as a scribe in the room. They don’t ask questions, do a physical exam or formulate a tentative plan. They don’t interact with the patient. A scribe is like a fly on the wall, recording what happens in the exam room.

If you are using scribes, that is a terrific way to unchain a physician from data entry. But, look at the list above and make sure your scribe is really a scribe. Don’t use the concept of scribing as a way to not enroll eligible professionals.